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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045002224
Report Date: 08/17/2021
Date Signed: 08/17/2021 01:12:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME:ALMOND BLOSSOM SENIOR CAREFACILITY NUMBER:
045002224
ADMINISTRATOR:RAMOS, EDUVIJESFACILITY TYPE:
740
ADDRESS:1036 BLACKMUIR COURTTELEPHONE:
(530) 342-1813
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:6CENSUS: 6DATE:
08/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:EMILY LANSERTIME COMPLETED:
10:45 AM
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Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a case management visit regarding an incident.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by staff upon entering the facility.

On 07/25/21 it was reported that a resident (Resident 1) slid out of his chair and suffered a cut to the top right of his scalp. An assessment was conducted by the staff person and the resident was sent to the local hospital. The resident had to have staples in his head to close the wound. The resident is doing well with his healing. In an effort to try and avoid this type of fall in the future, the resident has received a hospital bed and a wheelchair.

An exit interview was conducted, and a copy of the report was given to the administrator/staff person. No deficiencies cited.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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